The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with 2-person assist.”. The charge nurse tells the nurse to add which missing element to complete the goal?

Performance criteria.

Client behavior.

Conditions or modifiers.

Target time.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Performance criteria describe the measurable qualities or the level of performance expected from the client, such as the distance walked or the accuracy of a task. In the stated goal, the phrase with 2-person assist already serves as a performance criterion or modifier by defining how the transfer must occur. Therefore, the performance criteria are technically present in the goal, and this is not the missing element.

Choice B rationale

Client behavior represents the specific action the client is expected to perform, which must be observable and measurable. In this clinical goal, the behavior is identified as the act of transferring from the bed to the chair. Since the action of transferring is clearly stated, the behavior component is already included in the nursing outcome statement and does not need to be added by the nurse.

Choice C rationale

Conditions or modifiers define the specific circumstances under which the behavior is to be performed, such as using equipment or receiving help. The phrase with 2-person assist acts as the condition for the transfer. Because these modifiers are already incorporated into the written goal, adding more conditions is not the primary requirement for completing this specific outcome according to standard nursing process guidelines.

Choice D rationale

A target time is a critical component of a SMART goal, indicating when the outcome is expected to be achieved. The current goal lacks a deadline, such as by discharge or within forty-eight hours. Without a specific timeframe, the nurse cannot effectively evaluate whether the client is progressing at an appropriate rate. Adding a target time ensures the goal is measurable and time-bound for evaluation.

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Correct Answer is B

Explanation

Choice A rationale

Waiting until after the second voided specimen is collected to start the 24-hour clock would result in an inaccurate total volume and incorrect concentration of solutes. The goal of the 24-hour urine collection is to measure the total excretion of substances like creatinine, protein, or electrolytes over a precise 1440-minute window. Starting at the second void would omit the urine produced between the first and second voids, leading to a significant underestimation of renal clearance.

Choice B rationale

The 24-hour urine collection begins by having the client empty their bladder and discarding that first specimen. This ensures that the urine collected starts from an empty bladder at a specific time. All subsequent urine for the next 24 hours, including the final void at the exact end of the 24-hour period, is saved in the container. This method captures all urine produced by the kidneys during the designated timeframe, providing a reliable measure of renal function.

Choice C rationale

The arrival of equipment does not dictate the start of the biological collection period. The timing must be synchronized with the emptying of the client's bladder to ensure the sample represents a true 24-hour window of renal filtration and excretion. Starting the collection based on equipment arrival rather than the client's voiding schedule would lead to a random timeframe that does not account for urine already present in the bladder from the hours prior to the start.

Choice D rationale

Starting with the last voided specimen of the day is incorrect because it does not allow for a full 24-hour cycle of monitoring. A 24-hour collection must span a complete day-night cycle to account for circadian variations in hormone levels and renal excretion rates. Beginning at the end of the day would be retrospective and logistically impossible for a forward-looking collection. The process must be prospective, starting with an empty bladder and ending exactly 24 hours later.

A. The bladder is distended. B. The bladder is empty. C. The bladder is cancerous. D. The bladder is normal.

Correct Answer is A

Explanation

Choice A rationale

A palpable bladder that rises above the symphysis pubis is a clear clinical sign of bladder distention. Normally, an empty or minimally filled bladder is located deep within the pelvic cavity and cannot be felt through the abdominal wall. When urine volume exceeds approximately 200 to 400 mL, the bladder expands upward into the hypogastric region, becoming palpable as a firm, rounded mass above the pubic bone.

Choice B rationale

If the bladder were empty, it would remain behind the symphysis pubis and would not be palpable during a physical assessment of the abdomen. An empty bladder contains very little volume and does not extend into the abdominal cavity. Therefore, finding a palpable mass in this location directly contradicts the conclusion that the bladder is empty. Normal residual volume is usually less than 50 mL.

Choice C rationale

While a bladder tumor could potentially cause a palpable mass, distention due to urinary retention is a much more common and immediate cause of a palpable bladder. A nurse cannot diagnose cancer based solely on palpation; such a conclusion requires diagnostic imaging, cystoscopy, and biopsy. Documenting the bladder as cancerous based only on a physical exam would be outside the nurse's scope and medically premature.

Choice D rationale

A palpable bladder above the symphysis pubis is not considered a normal finding in a healthy, recently voided adult. While it is a common finding in patients with urinary retention, it indicates an abnormal accumulation of urine that requires intervention or further monitoring. A normal bladder should not be felt until it is significantly full, and even then, it suggests the patient may need to void.

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The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with 2-person assist.”. The charge nurse tells the nurse to add which missing element to complete the goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider ordered a 24-hour urine specimen to test the renal function of a client admitted with acute renal failure. The nurse has prepared all the necessary equipment and has asked the client if they need to void. When will the 24-hour collection period begin?

Correct Answer is B

Explanation

The nurse is assessing a client lying in a supine position and finds that the client's bladder is palpable and rises above the symphysis pubis, but it is not close to the umbilicus. What will the nurse document?

Correct Answer is A

Explanation

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